North Dakota Health Care Power of Attorney Form - Free Download | Page 3
The North Dakota health care power of attorney is a legal document used by the grantor to authorize the attorney-in-fact to make decisions about his/her health care matters.
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You can, but are not required to, state your desires in the space provided below.
You should consider whether you want to include a statement of your desires
concerning life-prolonging care, treatment, services, and procedures. You can also
include a statement of your desires concerning other matters relating to your health
care. You can also make your desires known to your agent by discussing your
desires with your agent or by some other means. If there are any types of treatment
that you do not want to be used, you should state them in the space below. If you
want to limit in any other way the authority given your agent by this document, you
should state the limits in the space below. If you do not state any limits, your agent
will have broad powers to make health care decisions for you, except to the extent
that there are limits provided by law.)
In exercising the authority under this durable power of attorney for health care,
my agent shall act consistently with my desires as stated below and is subject to the
special provisions and limitations stated below:
a. Statement of desires concerning life-prolonging care, treatment, services, and
procedures:
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
b. Additional statement of desires, special provisions, and limitations regarding
health care decisions:
_______________________________________________________________
_______________________________________________________________
(You may attach additional pages if you need more space to complete your
statement. If you attach additional pages, you must date and sign EACH of the
additional pages at the same time you date and sign this document.) If you
wish to make a gift of any bodily organ you may do so pursuant to North Dakota
Century Code chapter 23-06.2, the Uniform Anatomical Gift Act.
5. INSPECTION AND DISCLOSURE OF INFORMATION RELATING TO MY
PHYSICAL OR MENTAL HEALTH. Subject to any limitations in this document, my
agent has the power and authority to do all of the following:
a. Request, review, and receive any information, verbal or written, regarding my
physical or mental health, including medical and hospital records.
b. Execute on my behalf any releases or other documents that may be required in
order to obtain this information.
c. Consent to the disclosure of this information.
